Why should we continue to learn?

F ormal under-graduate and post-graduate education prepares us with the basic “potential” to implement health care. Actual medical practice and responsibilities place demands on the individual to maintain a relevant level of knowledge, skills, attitudes and even behaviour, to improve standards of practice and patient care. The tensions that arise at a personal level are knowing what to learn, where to find it and how to record and measure it against peer groups or local standards. CME and CPD Continuing Medical Education (CME) and Continuing Professional Development (CPD) are traditionally thought of as the methods by which medical providers maintain knowledge and skills that are up to date with the latest medical advances. In the past, CME events mostly consisted of meetings and printed material. It was not particularly individualised to specific needs and there were no requirements as to how much or what type Continuing professional development (CPD)

F ormal under-graduate and post-graduate education prepares us with the basic "potential" to implement health care. Actual medical practice and responsibilities place demands on the individual to maintain a relevant level of knowledge, skills, attitudes and even behaviour, to improve standards of practice and patient care. The tensions that arise at a personal level are knowing what to learn, where to find it and how to record and measure it against peer groups or local standards.

CME and CPD
Continuing Medical Education (CME) and Continuing Professional Development (CPD) are traditionally thought of as the methods by which medical providers maintain knowledge and skills that are up to date with the latest medical advances. In the past, CME events mostly consisted of meetings and printed material. It was not particularly individualised to specific needs and there were no requirements as to how much or what type F ormal under-graduate and post-graduate education prepares us with the basic "potential" to implement health care. Actual medical practice and responsibilities place demands on the individual to maintain a relevant level of knowledge, skills, attitudes and even behaviour, to improve standards of practice and patient care. The tensions that arise at a personal level are knowing what to learn, where to find it and how to record and measure it against peer groups or local standards.

CME and CPD
Continuing Medical Education (CME) and Continuing Professional Development (CPD) are traditionally thought of as the methods by which medical providers maintain knowledge and skills that are up to date with the latest medical advances. In the past, CME events mostly consisted of meetings and printed material. It was not particularly individualised to specific needs and there were no requirements as to how much or what type Please support us We rely on donations/subscriptions from charities and generous individuals to carry out our work. We need your help.
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About this issue
Being a health professional is not easy. Initial optimism is tempered by the reality of everyday practice. You intend to 'do no harm' but you forget a lot of what you have learnt. You try and keep up to date but there are time pressures and the rest of life to contend with. You may work in a remote area where there are no colleagues to talk to and little access to information.
But help is at hand. In this edition of the journal the rationale for Continuing Professional Development (CPD) is explained. There are articles on how to manage your own learning and illustrative case studies from practising eye care professionals. There are new ways of undergoing self-directed learning which are stimulating and fun, and there is information on where to find good resources.
• Electronic medical records are making patient outcomes more transparent. This will drive health care workers to self-improvement through effective CPD.
All of these factors are increasing the demand for CPD. This demand produces revenue-generating opportunity for CPD providers (e.g. ophthalmic societies) to fund their non-CPD activities and achieve their goals.

Universal health coverage and Sustainable Development Goals
Universal health coverage through increased availability, accessibility, quality of care and service provision can only be achieved through appropriately trained and equipped health personnel. In 2015 the United Nations General Assembly adopted 17 Sustainable Development Goals with the intent to end poverty, protect the planet and ensure prosperity for all. One of the challenges to achieving this is the lack of accessible health care around the world. This is certainly true for eye health. Most countries don't have a sufficient number of ophthalmologists, optometrists and allied ophthalmic personnel.
Compounding the problem, skilled eye health care workers are often concentrated in large cities, leaving much of the country with poor access to eye care. In addition, skilled eye care workers may be unable to provide services within their scope of practice. For instance, although ophthalmologists provide surgical eye care, in some countries as few as 15% perform surgery.
Solutions to eye care access include the creation of more eye care workers, improved efficiency through eye care team training and expanding/improving abilities of current eye care workers. Quality of clinical and surgical care within a health system is dependent on practitioners engaging with established standards of practice, implementing governance and managing budgets, as part of their routine range of activities.
All of these solutions and activities require effective CPD.

Conclusion
Thus, CPD is evolving and is crucial for the eye care worker's continuing competence. During training the principle of life-long learning must be emphasised. CPD allows staff to be confident in their skills and facilitates the efficiency, effectiveness and quality of the eye care team. It helps assure the best outcomes for the maximum number of patients and improve access to high quality eye care globally. The availability of effective CPD is improving but the demand and its increasingly mandatory nature will necessitate ever-expanding opportunities for quality CPD.
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Disclaimer
Signed articles are the responsibility of the named authors alone and do not necessarily reflect the views of the London School of Hygiene & Tropical Medicine (the School). Although every effort is made to ensure accuracy, the School does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.
The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the School in preference to others of a similar nature that are not mentioned. The School does not endorse or recommend products or services for which you may view advertisements in this Journal.

ARAVIND EYECARE SYSTEM
Nurses undergoing CPD together. Aravind Eye Care System.

CPD IN PRACTICE
T he Royal College of Ophthalmologists (RCOphth) started its CPD programme in 1996 and is open to all fellows, members and non-members (non-members are charged an annual fee). The programme is designed for those working in the National Health Service (NHS) as well as those working outside of it. CPD is an online system.
The programme follows a five year cycle of CPD activity in which 250 credits need to be accumulated. Participants are expected to accumulate 50 credits per year. The system allows doctors to record their educational activity which they are then able to present at their appraisal and revalidation. It supports them in specific changes in practice and career development. Points given by the College are based on one point equating to one hour of educational activity.
The College has a mechanism for approving meetings, symposia, conferences etc. for allocation of CPD points. An application is completed and sent to the College for approval. The College holds a list of approved activities that are reviewed every five years in the UK, Ireland and overseas. Any new regular meeting will need to have run successfully for three years or three occasions before being considered for inclusion on the approved list. Meetings accredited by other Colleges for CPD purposes are all recognised by the College.

CPD categories
Categories assist people to classify CPD and to ensure that a balance of activities is undertaken. There are four categories (see Table 1).

How to record CPD
Participants should record CPD points on a continuous basis and plan what they wish to attend in advance as far as possible. What actually happens is that this is often left to the last minute when preparing for appraisals. All this can be recorded on the online system on a regular basis. CPD records are an excellent way to demonstrate that knowledge and skills are up to date.
It is the responsibility of participants to ensure that they undertake a range of CPDs that reflects the local and national needs of their practice and their own learning needs.

Keeping a diary
This does not need to be a complex process and for many years the College used a paper version before it switched to an online system (see Figure 1). This can be as easy as having an ordinary paper diary and writing down your events and points on the days that you attend them. Again this can be prepared in advance and help with the planning of your educational needs. Providing a self-made diary which can be photocopied and made into a booklet and carried round for easy access is also a cost-effective option.

Reflective practice
Reflection will help a doctor assess whether their learning is adding value to the care of their patients and improving the services in which they work; they should record any impact (or expected future impact) on their performance or practice. Reflection should also occur as soon as possible following the event as this will make it more meaningful.
Reflection drives change in performance and is the key to effective CPD. The General Medical Council's 'Good medical practice' (www.gmc-uk.org/Good_medical_ practice___English_1215.pdf_51527435.pdf) requires you to reflect regularly on your standards of medical practice. Reflection must be integral to your own development plan, appraisal and job planning discussions.
You must reflect on all aspects of your professional work. This should be informed by discussion with others and by specific evidence, such as data from audit, complaints and compliments, significant events, information about service improvements, results of workplace-based assessments and feedback from patients and colleagues.
Where an activity has not been formally approved for CPD, it is the responsibility of the participant to record the activity and document the learning achieved. Learning may reinforce existing good practice as well as provide new knowledge.
How you record your reflective practice is important and examples are given below to demonstrate this.

Example 1
Individual X attends a full day symposium on glaucoma. The symposium was approved for a total of six CPD points.
A leading specialist in the field of glaucoma with a purely glaucoma practice. i.e. only one point out of a possible six allocated as little new knowledge/skills gained.

Example 2
Individual X attends a full day symposium on glaucoma. The symposium was approved for a total of six CPD points.
A general ophthalmologist with no glaucoma subspecialty interest. i.e. sufficient new knowledge/skill gained to allocate the maximum number of points.

Example 3
An ophthalmologist attends a time management course that was approved for two CPD points. 2 Informal learning -routine reading with no pressure. I subscribe to ophthalmology journals and newsletters -especially the free online ones. I subscribe to online CPD sites, webinars, and e-CPD sites and download articles that I need to read. I find that when the next patient is sitting in front of me somehow my head will automatically sift through the good and bad articles that I have read, and help me reach a sensible decision.
3 I keep a network of mentors which has proved invaluable. I have been inviting these mentors to come and teach me surgery or research in my own set-up with my staff. This helps me and my team to keep up to date with new techniques even after they leave.

6
COMMUNITY EYE HEALTH JOURNAL | VOLUME 30 | NUMBER 97 | 2017 W hen I graduated as an ophthalmologist in Africa I really felt I had achieved my goal!; but the reality of working in the field was very different. With each patient, my knowledge and skills were challenged, I found that surprisingly, many patients knew much more than I thought they did.
Even in a small town like Nakuru patients asked me questions such as "You say you cannot help me here, is there anywhere in the world I can get the help I need? I 'Googled' and found…" I soon realised that to answer them honestly I needed to know a great deal more. The intensity and the competitiveness of ophthalmology surprised me too. I was "here" and I needed to be "there". Being "there" meant staying on top of the game as far as all the pathology, conditions and treatments that I needed to know. The trouble is -"there" is constantly shifting with the advent of new techniques and equipment.
Besides clinical skills there were growing demands relating to management, communications and technology. First recognise your needs and then the path to learning and acquiring the skills can be through a formal or an informal process.
I have found it very useful to be an active member of my local ophthalmology society where I can participate in CPD activities. In Rwanda, my own institute is a registered CPD provider. When CPD became mandatory I found it easier to become more structured in my approach and avoid a last minute scramble for points in order to maintain registration with the Medical Council.
Mandatory CPD is often seen as a "stick", but it provides thematic guidance and structure that is often harder to organise on your own. I keep a folder on my laptop called CPD in which I drop all the activities as I do them so that when it comes to submitting to the council, my records are all in one place.

Conclusion
It is necessary to take ownership and responsibility for your own learning, have formal and informal processes in place and dedicate regular time for reading and keeping professional development continuous.

Keeping my professional development continuous
Keeping up professionally means knowing what is current and then selecting what is applicable to your work. This requires a personal commitment to recognise the need, find the time and seek resources. The process is lifelong and can become part of your routine.

Identifying the need
Clinicians are usually very busy with their clinical practice and may not have thought about their needs relating to CME and CPD. However, effective CPD requires prior preparation. Every clinician may experience a feeling of unease or lack of confidence when faced with a difficult situation. The underlying cause may be a lack of knowledge or skill, which if remedied would enhance the outcome for the patient and the job satisfaction for the clinician.
Identifying the need requires being honest with oneself and realising that everyone, whether junior or senior members of staff, has the potential and an obligation to maintain standards of practice and patient care (see article on page 13 for various reasons for keeping up to date).
Different types of CPD activities may be chosen according to the identified needs. The following table is an example of how a clinician can identify what CPD activity may be relevant for them.

How to figure out what CPD/CME you need
Do you feel totally in control of every situation? We need to be honest about the gaps in our knowledge or skills, keep motivated and find solutions to the challenges.

Knowledge gap
Skills updating Acquisition of competency

Performance demonstration
Failed treatment of a certain condition. Need to find out if there has been a change in the treatment of the condition and factors associated with recurrence e.g. squamous cell carcinoma of the conjunctiva.
Noting lack of skill in using certain equipment. Need to understand or refresh techniques e.g. applanation tonometry, indirect ophthalmoscopy, use of ophthalmic (BIO) lenses.
Lack of confidence in treatment of certain conditions. Practice required.
How to teach others on the subject of interest.
Sharing and dissemination to peers through publication. Inability to diagnose a clinical condition by matching the symptoms and signs. Need to work out the differential diagnosis by accessing information.
Noting deficiency in performance of a surgical procedure: e.g. cataract surgery (small incision or phacoemulsification).
Inadequate up-to-date information on certain conditions common in your area. Need clinical guidance. e.g. classification and treatment of diabetic retinopathy or retinoblastoma.
Noting inability to perform or interpret a procedure after acquiring a new diagnostic machine e.g. A scan biometer, Optical Coherence Tomography (OCT), iCare tonometer, visual field machine.
Lack of confidence in performance of certain steps in a surgical procedure.
Practice required.
How to share what you are doing with others. Listening, learning and sharing your knowledge with others to improve your performance. Inadequate knowledge about a common condition in your area that was not learnt during basic training e.g. low vision and low visual aids.
Learning a new surgical skill after getting new equipment e.g. learning to perform phacoemulsification with a new machine.

Motivation
It is necessary to be motivated to attend CME/CPD training. Motivating factors broadly fall into 'carrot' and 'stick' categories. It is best to be motivated by positive factors (carrots) that lead to fulfilment, increased self-esteem and good outcomes for your patients rather than feel that CPD is an unnecessary chore that has to be done to avoid a penalty (stick).

Challenges
Busy clinicians face a number of challenges for attending CME/CPD. However keeping up to date is so important that every effort must be made to overcome the challenges and find solutions (see Table 2).

Challenges Solutions
• Identifying the need.
• If things go wrong -keep a record to reflect on and identify gaps that can be filled by CPD.
• Ask colleagues how they keep up to date.
• Use appraisal with line managers, for advice on choosing relevant CPD activities.
• Inadequate time: Most of the time clinicians are busy in their clinics from morning to evening especially in low resource settings.
• Remember that keeping up to date is as important as seeing patients in the clinic or the operating theatre.
• Think about time management or take a course on time management.
• Set aside dedicated time to read (for example the Community Eye Health Journal).
• Keep a CPD diary and refer to it! • Because of their busy schedule they sometimes fail to get permission to attend external CPD/CME as they need to work. e.g. attending conferences.
• Apply for study leave or funding in advance.
• Keep a diary.
• Not knowing where to get CPM/CME especially for low resource settings.
• Discuss with colleagues how they manage.
• Look for online courses. Many can be downloaded and used offline.
• Lack of travel expenses to attend external CME/ CPD -provision of CPDs at a central area within the country where many clinicians can attend.
• Identify the most useful meetings, courses or events and opportunities for CPD and lobby your manager.

How and where to start
Organisations appreciate the value of Continuing Professional Development. However, most organisations tend to be too "busy" to ensure that it happens systematically. It is often helpful for organisations to have CPD sessions planned and scheduled -say, during a given month every year. This offers regularity and helps the team to anticipate and prepare for it.
When organisations prepare for their CPD sessions, topics should be chosen with a purpose. Often, when arbitrary themes for CPD are selected -it runs the risk of being uninteresting or irrelevant to the team. CPD can be a powerful stepping stone towards organisational improvement and selection of topics can be identified through an ongoing process of continuous improvement or emerge from a systematic analysis of patient safety incident reports, patient satisfaction reports, and other information collected on an ongoing basis.
Topics can also be selected based on new technology, methods or products that are being introduced into the organisation. Reassessment of individual skills can help to identify gaps that could be addressed through retraining. Make sure that the topic you choose is in alignment with your overall institutional goals.
As CPD sessions are being planned, it is good to pin down responsibilities for different aspects of the process: • training needs analysis • communication • participation • training delivery and follow-up It is often useful to include a representative of the audience as a CPD committee member to ensure relevance. This helps to build champions not only for the training, but for the resulting improvement process itself.

Essentials
Ideally all CPD should be developed using good training design principles. Learning objectives should be laid down and clearly accounted for by defining the overall outcomes expected. It is essential to have a clear and focussed goal for the CPD session.
CPD sessions should avoid using old-fashioned didactic lecture format and be designed to be more engaging and interactive. The CPD audience comes with good baseline knowledge and rich experience from the field work. They can be used as a resource in the classroom by facilitating learning from each other. Performance data and real stories from within the organisation are a great resource to make the learning relevant. They also serve to emphasise the problem and highlight the opportunity to improve.
It is important to ensure that the training session includes an assessment element: e.g. a quiz or short test to gauge learning and reinforce the lesson. There are a wide array of interactive group techniques , including role playing and small group demonstrations that can reveal the extent to which learners have learned. This assures that the CPD is accountable and is grounded upon expected outcomes.

Common pitfalls
Lack of institutional "buy-in": CPD activities can be ineffective, especially when they are deployed as a standalone event without a champion among the organisation's leadership. The audience must be able to perceive the CPD activity (and the overall improvement process) as a priority for the organisation and directed towards improving patient care.
Have the right people involved: Leaders must ensure that CPD sessions are seen as an important investment.
Plan that the right staff are sent to the CPD. Where only a headcount is expected, often the most junior staff are sent to the training when they alone cannot influence the improvement process.

How to 'do' CPD with your team (from the organisation's perspective)
CPD is not only the individual's responsibility but that of the organisation too. A planned programme, well designed and interactive, with an assessment element, will help avoid the pitfalls and motivate and encourage the team.

DHIVYA RAMASAMY
Using 'role play' to teach patient communication. INDIA opportunity for participants to practise the skill in class and learn from each other's mistakes. Similarly, role plays and videos can help to engage the audience for "soft" themes such as patient-centred care and communication.
Maintain relevance for the audience: Trainers or faculty must have enough experience and competence on the topic and be given sufficient time to prepare for the session. It is also important for the trainers to be aware of the "level" of the learners -a pre-test often helps to do this. It also helps the audience open up to what is going to be taught. If the faculty is from outside the organisation, it helps to "orient" them to the organisation. This will help the faculty to adjust the style and language appropriate for the audience.
State expectation from the onset: Is the CPD structured to help the audience translate what is taught in their own workplace? It is important to explicitly bring out how the training programme connects to the work of each staff member and what they are expected to change or do after the CPD.

How to encourage and motivate the team over the long term
As CPD activities are usually meant to be a part of a change or continuous improvement process, it is important to maintain the motivation of the learner, beyond the session itself. Recognition -a badge or certificate announcing that they have completed the training -can help create a sense of achievement.
Improvement plan: Improve patient communication by creating awareness for importance of good patient communication and train doctors and allied health personnel on best practices for effective communication.

CPD on Patient Communication:
A half-day workshop focused on patient communication using videos of patient interviews and patient stories to sensitise staff about patient perspectives. A qualified counsellor was invited as faculty and given patient stories to "orient" her to the problem. The audience were engaged in the learning process using stories and role-plays. Clear guidelines were laid out for patient communication.
Outcome measures: Percentage of "Excellent" ratings on overall satisfaction. Learning together with other eye care professionals from different countries, cadres and local settings exposed me to many new experiences and ideas. The Global Blindness course inspired me to think about how our free rural outreach cataract programme could address some of the patient barriers we were seeing. Around 25% of the people who were offered surgery did not arrive at the hospital afterwards. From a survey with patients we identified that patients were afraid of a poor quality surgical outcome and we were carrying out surgeries during harvest which meant there was a lack of people to escort them to hospital.
We addressed these barriers through counselling patients and their relatives about surgical quality and we re-scheduled the timing of surgeries. Taking the Global Blindness course helped me reflect on and improve our eye care outreach programme.

Lila Puri Ophthalmologist, Nepal
I took the Global Blindness course (http://iceh.lshtm. ac.uk/oer/) while practising as an ophthalmologist in a high volume community eye hospital in Nepal.
Our programme was already delivering many of the public health activities covered by the course but I still found it very useful for refreshing my knowledge on both the principles of public health for eye care and its application. The course was a great opportunity to hear from world experts in public health eye care -I felt as if I was in the class physically! We were also able to share our experiences, ideas and strategies. For a short six-week course, the content was very comprehensive. I had new insights into planning and prioritising for sustainable, equitable and accessible services. This was very helpful for me as I have a decision-making position in my organisation.
Another great outcome of this course was that it motivated me to go on to formal study and apply to LSHTM where I am now studying for the Masters in Public Health Eye Care. My studies here have shown me even more how useful the Global Blindness course is as a resource for all eye care cadres.
Case study 2 Case study 1 "We need assessment tools. We need support. We need faculty development. And I think we also need some patience. This is going to take a little bit of time." J. Mark Walton, MD, FRCSC; assistant dean of Postgraduate Medical Education at McMaster University C ontinuing Professional Development (CPD) incorporates Continuing Medical Education (CME) as one modality and embraces other relevant wide-ranging educative means and competencies required to practise high quality medicine.
Society has a longstanding social contract with the medical profession. Life-long learning is the scaffold of safe and up-to-date practice which incorporates healthcare workforce accountability. CPD is a cyclic, continuous, self-directed, practice-based learning process, tailored to personal learning needs and matching learning to practice.
Several factors need to be considered when determining the need for regulation of CPD: • Content: What is new and required within the

CPD Stakeholders
Healthcare professionals, societies and colleges, regulators, educators, policy makers and healthcare authorities, patients and public are all CPD stakeholders. Meaningful coordination amongst them is fundamental to create an integrated and effective CPD system that meets the needs of the profession, patients and public. Open communication facilitates the identification of gaps in healthcare delivery, hence guiding societies to tailor CPD activities accordingly.

Practically -how does it work?
Societies and Colleges as medical professional bodies were identified as having the main responsibility to set-up the CPD planning committee. This group should ideally include administrators, healthcare professionals, researchers, educationalists and experts in content. There should be individuals with healthcare expertise who are competent in leadership, collaboration, professionalism, communication, scholarship and advocacy.
They must be able to represent the members, ensure that educational content and instructional design match practical needs and make the CPD system more effective and accepted overall.
The CPD committee are required to manage a range of tasks that include those shown on Figure 1 over the page.

Setting and maintaining standards
Despite the worldwide diversity of approaching CPD, there is mutual agreement around a set of desirable and implementable global standards. This should stimulate the creation of CPD systems with a minimum requirement that are relevant to each region.
Considering the CPD integrated and holistic view, the International Council of Ophthalmology (ICO) created the "ICO Guide for Effective CPD/CME" a practical guide to the relevant core concepts and basic questions of CPD/CME bearing in mind the perspectives of participants, educators, regulators and providers 1 . An effective CPD system (using the acronym SCAR) should encompass professional development as: • Systematic by following a personal development plan based on the cyclic learning process involving reflection, planning, learning and assessing. Structuring CPD -a nine-step process (Figure 1) The ICO has proposed a comprehensive approach to design a structured CPD system. A) Allocation of resources optimises the assignment of personnel and assets to meet requirements.
B) Situational analysis allows understanding of current practices and the identification of gaps.
C) Content of the programme should: • be relevant, based on a needs assessment and continuously updated to meet the public needs.
• flexible to facilitate self-directed and practice based learning, allowing learning outside medical expertise, consider social or web-based or informal learning, and include inter-professional education.
• be delivered through appropriate multimodal formats, adapted to personal learning styles and supported by faculty development to use the best educational strategies.
D) The structure of the programme should take into account the length of the CPD cycle and its relationship to appraisal and licensure.
E) Facilitate translation of new learning into practice by providing opportunities to disseminate and reinforce it. Documentation to demonstrate individual progression is an essential component of an effective CPD system.
F) Administration and management should ensure a clear communication to the members about the programme structure, educational activities and important dates eventually using the society or college website as a cost-effective means. Individual notifications will help to ensure cycle completion, award the completion certificate or propose a remediation plan.
G) Accredited educational activities should aim for a change in practice and the committee should provide accreditation guidelines. Commercial sponsorship should be regulated and biased education avoided ( Figure 2).
H) Programme implementation should emphasise that the best healthcare outcomes are tied to the concept that CPD is a professional requirement accomplished through lifelong learning and not an outward imposition.
I) Programme assessment should include three components: 1 system monitoring and self-regulation 2 educational activities assessment 3 professional regulation.

Recording and assessing CPD
A robust CPD framework should include an assessment component. The system should ensure continuous monitoring and self-regulation.
All outcome levels of educational activities should be assessed: participation, satisfaction, learning (knows, knows how, shows how) performance (does) patient and community health. Educational activities should align: gap analysis -needs assessment -learning objectivescontent/ delivery format -assessment. Professional regulation resides in a clear demonstration of life long learning translated into practice. Either hard copy or online, portfolios are excellent assessment and learning tools, that emphasise the reflective component of an effective CPD system. They should mirror the activities undertaken, why they were pursued and how they helped to enhance practice. Societies and colleges should create and provide an effective system based on the portfolio to record the ongoing personal development plan.
Regulation should be informed by the profession and viewed as the means to effectively demonstrate professional progression and accountability. CPD systems are moving towards the demonstration of a mandatory set of requirements, either based on credit units awarded by the time spent on educational In either one the inherent professional obligation to society should remain as a primary imperative.

Conclusion
CPD should be a local effort, depending on local disease patterns and health system requirements. Of all medical education stages, CPD is the least formally structured and can be the most complex to create and assess given the diversity of curricula, educators, regional healthcare needs, professional aspirations, complexity of working environment and multiple stakeholders.
CPD is a primary obligation to the patients and the public. The paradigm has been shifting to place the healthcare team in the centre of CPD good practice. Professional bodies should maintain and reinforce their core role in providing CPD guidelines, standards, and benchmarks creating systems to effectively record and share information and documents among members. Professional bodies should involve all stakeholders engaged in meeting the public healthcare needs and build a CPD system that is efficient, transparent, credible, accountable, affordable, easy to manage and administer, driven within the profession, and flexible to the community health care needs.
The educational programme should be exempt from industry influence and cover multimodal practice-based activities aiming for practice change.
Managing CPD systems should ideally include the audit and portfolio as components and be regularly self-assessed for improvement. To build this holistic view of CPD, the CPD planning committee members should themselves develop competencies of leadership, professionalism, communication skills, advocacy, scholarship, and collaboration. Twenty years ago, Demissie Tadesse was a young doctor who had completed his ophthalmic training in Italy but did not have the opportunity to practise his surgical skills for trichiasis. He remembers the early days of working back in his home country of Ethiopia. Looking back, he can see how a practical step between the theory he learnt in the classroom and his first surgery on a human eyelid would have eased the transition from theory to live surgery.
A comprehensive training approach, HEAD START, aims to bridge this gap. The innovative method, which is a result of wide collaboration between many partners, includes a surgical mannequin on which surgeons can practise their surgical skills. It helps new trainee surgeons to build their skills and confidence before performing surgery on their first patients as well as providing useful refresher training and regular professional development for experienced surgeons. The comprehensive training approach covers all aspects of preferred practices on addressing trichiasis developed by the International Coalition for Trachoma Control (ICTC).
With the scale-up in programming to trachoma elimination by 2020, much attention has focused on increasing the quantity of surgeries performed and the training of surgeons. Since Demissie became involved with HEAD START three years ago, it has become a widelyadopted training approach. All major funding initiatives supporting national trachoma programmes now use this ICTC recommended and WHO endorsed approach for newly-trained and experienced surgeons. To maintain high-quality training standards, all training is undertaken by certified national master trainers directly, rather than through the previously widely used (but now discouraged) cascade approach. The WHO now recommends mannequin-based training for trichiasis surgery as part of new and refresher trichiasis surgery training programmes. Now a certified global trainer, Demissie is playing a key role in disseminating the training and developing surgical skills with people of different backgrounds from all over the world, from Pakistan to Mozambique. In just a few years, he has seen how the approach is contributing to improving people's lives, "By following proper standards and certification, the HEAD START approach is putting global standards in the limelight. As a result, the impact will be very different because the focus of the training is on good quality outcomes, which will address the challenge of trichiasis recurrence that we have seen in the past." Demissie has seen first-hand how practising on a mannequin allows surgeons to improve their work by allowing them to assess their technique. Both trainees and experienced surgeons have been able to improve their technique including angle of incision and suture placement, as all the steps can be revisited by removing the eyelid cartridge from the mannequin. Even experienced surgeons have been surprised by the improvements they were able to achieve. A recent trainee from Niger reflected, "The mannequin permits one to have surgical skills before applying them on humans; it's a good initiative for perfection." Emily Gower, epidemiologist and trachoma expert who has played a key role in developing the approach, remembers the expressions on people faces when the cartridges were taken out in the very first training session that took place in Tanzania, "You could see the wheels turning in the surgeons' heads and that they were thinking 'I could do a better job by making these changes'." Going forward, a Seeing is Believing project in Ethiopia will support the maintenance of skills through remote monitoring of surgeons during the rainy seasons when fewer surgeries are performed. Over five months, the surgeons will undertake two surgeries a week on the mannequin and send the cartridges to a central office for review and monitoring. The innovative approach has also germinated thinking in other areas. USAID's Morbidity Management and Disability Prevention (MMDP) Project, inspired by HEAD START, is developing a similar mannequin training approach for lymphatic filariasis hydrocele surgical training.
The HEAD START approach is improving quality outcomes across the global trachoma elimination programme. Through its training of trainers and now also augmented by remote learning, it is truly providing a tool for continuing professional development and lifelong learning.

HEAD START -an innovative training approach for life-long learning
An innovative global training approach called HEAD START is bridging the gap between theory and live surgery, building skills for new trainees as well as providing continuing professional development for experienced surgeons.

EMILY GOWER
Surgeons undertaking training on the HEAD START mannequin.

Demissie
Tadesse MD, CBM Regional Eye Health Adviser, Addis Ababa, Ethiopia. M aking health information available and usable to all is a complex process not yet adequately addressed (see Figure 1). It has to be appropriate, high quality, timely, easy to understand, relevant for the location it will be used in, and provided in an appropriate format. For example, you cannot learn a new surgical skill by reading about it, a much better method is to take a course or watch a video, preferably one suited for the local need.

Isabella
Where do you find these resources and opportunities? Information, communications technologies (ICTs) such as the internet are a promising mechanism to help address the health workforce information needs. Health workers need access to ICTs but they also need strong information and computer skills to search, select and make use of the available information and resources. 1 Availability of high-quality, up-to-date and locally relevant materials is limited in many settings and there is a lack of investment and organisational support for developing information and computer skills and the infrastructure needed to access printed and digital information.
In every setting, major health stakeholders need to continue to develop and implement knowledge management strategies to enable health workers to use the evidence-based information and knowledge available to them. 2,3 The following infographic aims to guide eye health clinicians, educators, managers and leaders on: A Identifying the information need B Developing a search strategy C Carrying out an effective online search D Finding sources of good eye health information and resources on the internet

Accessing good health information and resources
Health workers need to be able to access health information and resources to update and apply their knowledge and skills and continue their professional development.   ARAVIND We hope that you will also discuss the questions with your colleagues and other members of the eye care team, perhaps in a journal club. To complete the activities online -and get instant feedback -please visit www.cehjournal.org

Test your knowledge and understanding
This page is designed to help you to test your own understanding of the concepts covered in this issue, and to reflect on what you have learnt.